Surgical Pathology Cancer Case Summary

Protocol posting date: February 2020

DCIS OF THE BREAST: Biopsy

Notes:
This case summary is recommended for reporting biopsy specimens but is NOT REQUIRED for
accreditation purposes. Core data elements are bolded to help identify routinely reported
elements.

Select a single response unless otherwise indicated.

Procedure
___ Needle biopsy
___ Fine needle aspiration
___ Other (specify): ____________________________
___ Not specified

Specimen Laterality
___ Right
___ Left
___ Not specified

Tumor Site (select all that apply)

___ Upper outer quadrant
___ Lower outer quadrant
___ Upper inner quadrant
___ Lower inner quadrant
___ Central
___ Nipple
___ Clock position (specify): _____o’clock
___ Distance from nipple (centimeters): ______cm
___ Other (specify): _____________________
___ Not specified

Histologic Type (Note A)

___ Ductal carcinoma in situ (DCIS)
___ Paget disease
___ Encapsulated papillary carcinoma without invasive carcinoma
___ Solid papillary carcinoma without invasive carcinoma

Architectural Patterns (select all that apply) (Note B)

___ Comedo
___ Paget disease (DCIS involving nipple skin)
___ Cribriform
___ Micropapillary
___ Papillary
___ Solid
___ Other (specify: ______________________)

Nuclear Grade (Note C)

___ Grade I (low)
___ Grade II (intermediate)
___ Grade III (high)
Necrosis (Note D)
___ Not identified
___ Present, focal (small foci or single cell necrosis)
___ Present, central (expansive “comedo” necrosis)

Additional Pathologic Findings (Note E)

Specify: ____________________________

Microcalcifications (select all that apply) (Note F)

___ Not identified
___ Present in DCIS
___ Present in non-neoplastic tissue
___ Other (specify): ______________________________________

Ancillary Studies
Note: For hormone receptor and HER2 reporting, the CAP Breast Biomarker Template should be used.
www.cap.org/cancerprotocols.

Biomarker Studies
___ Pending

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